Authorization of Release of Information – Fillable Form

Authorization of Release of Information

Fairfield County Common Pleas Court. 224 East Main Street. Lancaster, Ohio 43130.

I, full name, date of birth, Social Security Number, hereby give my consent to an investigation, and or inspection, of my background and current circumstances by probation officers and court officials of the Fairfield County Common Pleas Court.

I hereby authorize the release of any and all records, including, but not limited to, records held by Juvenile Court, including any sealed records, Children’s Services, Department of Job and Family Services, The Recovery Center, Mid-Ohio Psychologic Services, New Horizons, Buckeye Counseling Services, The Community Transitions Center, the Fairfield County ADAMH Board, the Ohio Department of Medicaid, Fairfield County Child Support Enforcement Agency, The Social Security Administration, and any agency, department, or business that the Courts or its representatives deem appropriate to seek information from.

Purpose or need for disclosure: To provide information to the Court for the purpose of obtaining information that will be useful in determining whether I am repeat offender and or eligible for community control, or to provide information on program participation, evaluation of social, medical and psychological problems, and reports on evaluations, findings, prognosis and recommendations for treatment.

This is a reciprocal release and allows the Fairfield County Common Pleas Court Community Control Department to release information to the above mentioned parties.

This consent to disclose may be revoked by me at any time except to the extent that action has been taken in reliance thereon.

This consent, unless explicitly revoked earlier, expires upon the completion of the defendant’s case with a finding of Not Guilty or the probationer’s term of probation on.

For Community Control. Acknowledgement, Agreement, and Additional Terms and Conditions of Community Control. I agree to permit the Court, Community Control Officers, or other appointed persons, to completely investigate and monitor my activities.

For Community Control Application Only. By consenting to this investigation and authorizing release of records, I do not admit any guilt or waive any rights. I fully understand, however, that any report prepared as a result of this investigation will be submitted to the Court.

I hereby state that I have read, understand, and fully agree to the above.

Defendant or probationer signature. Date. Witness signature. Date.

I hereby give my consent to an investigation, and or inspection, of my background and current circumstances by probation officers and court officials of the Fairfield County Common Pleas Court. I hereby authorize the release of any and all records, including, but not limited to, records held by Juvenile Court including any sealed records, Children’s Services, Department of Job and Family Services, The Recovery Center, Mid-Ohio Psychologic Services, New Horizons, Buckeye Counseling Services, The Community Transitions Center, the Fairfield County ADAMH Board, the Ohio Department of Medicaid, Fairfield County Child Support Enforcement Agency, The Social Security Administration, and any agency, department, or business that the Courts or its representatives deem appropriate to seek information from. Purpose or need for disclosure: To provide information to the Court for the purpose of obtaining information that will be useful in determining whether I am repeat offender and or eligible for community control, or to provide information on program participation, evaluation of social, medical and psychological problems, and reports on evaluations, findings, prognosis and recommendations for treatment. This is a reciprocal release and allows the Fairfield County Common Pleas Court Community Control Department to release information to the above mentioned parties. This consent to disclose may be revoked by me at any time except to the extent that action has been taken in reliance thereon. This consent unless explicitly revoked earlier expires upon the completion of the defendant’s case with a finding of Not Guilty or the probationer’s term of probation on.